TITLE 56

PUBLIC ASSISTANCE AND WELFARE

CHAPTER 2

PUBLIC ASSISTANCE LAW

56-226.  Medicaid fraud control unit. (1) There is hereby established in the office of the attorney general the medicaid fraud control unit which shall have the authority and responsibilities as set forth in this section.

(2)  Notwithstanding the authority and responsibility granted to the director of the department to provide for fraud control in other aspects of public assistance and public health programs, the medicaid fraud control unit shall have the authority and responsibility to conduct a statewide program for the investigation and prosecution of violations of all applicable Idaho laws pertaining to fraud in the administration of the medicaid program, the provision of medical assistance and in the activities of providers of medical assistance and services under the state plan. Further, upon approval of the inspector general of the relevant federal agency, the office of the attorney general shall have the authority and responsibility to investigate and to prosecute violations of any aspect of the provision of health care services and activities of providers of such services under any federal health care program as defined in 42 U.S.C. section 1320(a)-7b(f)1, if the suspected fraud or violation of law in such investigation or prosecution is substantially related to the state plan. The medicaid fraud control unit shall be under the exclusive control of the attorney general and be separate and distinct from the department. No official from the department shall have authority to review or override the prosecutorial decisions made by the medicaid fraud control unit.

(3)  The medicaid fraud control unit shall also:

(a)  Review complaints of abuse or neglect of medicaid recipients in health care facilities which receive payment pursuant to the state plan and may review complaints of the misappropriation of patients’ private funds in such facilities;

(b)  Review complaints of abuse or neglect of medicaid recipients residing in a board and care facility; and

(c)  Review complaints of abuse or neglect of medicaid recipients or the misappropriation of medicaid recipients’ private funds in other settings in which the provision of medicaid services is involved.

(4)  The medicaid fraud control unit shall attempt to collect or refer to the department for collection overpayments that are made to providers of facilities under the state plan or under any federal health care program to health care facilities that are the result of fraudulent acts and that are discovered by the medicaid fraud control unit in carrying out its responsibilities under this section. Notwithstanding any other provision of Idaho Code, all funds collected by the medicaid fraud control unit in accordance with this subsection (4) shall be deposited into the state general fund.

(5)  The office of the attorney general shall employ such auditors, attorneys, investigators and other personnel as are necessary to carry out the responsibilities of the medicaid fraud control unit as set forth under this section.

(6)  The office of the attorney general shall submit to the secretary of the federal department of health and human services applications and reports containing such information as is determined by the secretary by regulation to be necessary to meet the requirements of subchapter XIX, chapter 7, title 42, U.S.C.

(7)  In carrying out its duties and responsibilities under this section, the medicaid fraud control unit may:

(a)  Request and receive the assistance of any prosecutor or law enforcement agency in the investigation and prosecution of any violation of any applicable Idaho laws pertaining to fraud in the administration of the medicaid program, the provision of medical assistance and in the activities of providers of medical assistance and services under the state plan;

(b)  Enter upon the premises of any provider participating in the medicaid program to:

(i)   Examine all accounts and records that are relevant in determining the existence of fraud in the medicaid program;

(ii)  Investigate alleged abuse or neglect of medicaid recipients; or

(iii) Investigate alleged misappropriation of patients’ private funds. The accounts or records of a nonmedicaid recipient may not be reviewed by, or turned over to the medicaid fraud control unit without the patient’s written consent or a court order; and

(c)  Notwithstanding any other provision of law, upon written request have full access to all records held by a medicaid provider, or by any other person on his or her behalf, that are relevant to the determination of the:

(i)   Existence of civil violations or criminal offenses under this chapter or related offenses;

(ii)  Existence of medicaid recipient abuse, mistreatment or neglect; or

(iii) Theft of medicaid recipient funds.

No person holding such records shall refuse to provide the medicaid fraud control unit access to such records for the purposes described in this section on the basis that release would violate the medicaid recipient’s right of privacy or privilege against disclosure or use or any professional or other privilege or right.

(8)  The medicaid fraud control unit shall safeguard the privacy rights of medicaid recipients to avoid unnecessary disclosure of personal information concerning named medicaid recipients. The medicaid fraud control unit may transmit such information that it deems appropriate to the department and to other agencies concerned with the regulation of health care facilities or health professionals.

(9)  The medicaid fraud control unit shall be permitted to seek court-ordered restitution as reimbursement for the cost of investigation from those individuals successfully prosecuted for violations of any applicable Idaho laws pertaining to fraud in the administration of the medicaid program, the provision of medical assistance, or the activities of providers of medical assistance and services under the state plan. Any restitution payments received pursuant to this section shall be deposited in the state general fund.

(10)  The attorney general shall have the authority to adopt rules necessary to implement the duties and responsibilities assigned to the medicaid fraud control unit under this section.

(11) As used in this section:

(a)  "Board and care facility" means a provider of medicaid services in a residential setting which receives payment from or on behalf of two (2) or more unrelated adults who reside in such facility, and for whom one (1) or more of the following is provided:

(i)   Nursing care services provided by, or under the supervision of, a registered nurse, licensed practical nurse or certified nurses aide; or

(ii)  A substantial amount of personal care services that assist residents with the activities of daily living, including personal hygiene, dressing, bathing, eating, toileting, ambulation, transfer of positions, self-medication, body care, travel to medical services, essential shopping, meal preparation, laundry and housework.

(b)  "Department" means the Idaho department of health and welfare.

(c)  "Director" means the director of the Idaho department of health and welfare.

(d)  "Medicaid" means Idaho’s medical assistance program.

(e)  "Provider" means any individual, partnership, association, corporation or organization, public or private, which provides residential or assisted living services, certified family home services, nursing facility services or services offered pursuant to medical assistance.

(f)  "Recipient" means an individual determined eligible by the director for the services provided in the state plan for medicaid.

(g)  "State plan" means the Idaho state plan pursuant to subchapter XIX, chapter 7, title 42 U.S.C.

History:

[56-226, added 2007, ch. 341, sec. 4, p. 1005; am. 2024, ch. 228, sec. 1, p. 803.]